Necrotizing

Ulcerative
Periodontitis

Associate
professor
Dr Alaa Moustafa
Attia

Necrotizing
Ulcerative
Periodontitis
NUP may be an extension of
necrotizing ulcerative gingivitis
(NUG)
into
the
periodontal
structures, leading to periodontal
attachment and bone loss.
NUP and NUG may be different
diseases
Many authors suggested that the

Nomenclature
Term NUP was first adopted at
the 1989 World Workshop in
Clinical Periodontics.
Old
name
was
gingivoperiodontitis

NU

incidence
More cases of NUP were being
described
in
immunocompromised
patients,
especially
those
who
were

Differences of NUG/NUP
The distinction between
the two conditions (NUG
and NUP) as separate
diseases has not been
clarified, but they are
distinguished
by
the
presence or absence of
attachment and bone loss.

Clinical
features

Clinical features of
NUP 1

Similarity to NUG:

Similar to NUG, clinical cases of

NUP are defined by necrosis and
ulceration of the coronal portion
of the interdental papillae and
gingival margin, with a painful,
bright red marginal gingiva that
bleeds easily.
Show
gingival
crater
on
interdental papillae.

Clinical features of
NUP 2

NUP distinguished by:

By the destructive progression of
the
disease
that
includes
periodontal attachment and bone
loss.
Deep interdental osseous craters
demonstrate periodontal lesions
of NUP.
Gingival
marginal

lesion
destroys
epithelium

the
and

Clinical features of
NUP 3

Periodontal pockets are formed

because the junctional
epithelial cells remain viable
and can therefore migrate
apically to cover areas of
connective tissue loss.
Tooth mobility
Ultimately tooth loss.

Clinical features of
NUP 4
NUP patients may present with:
Oral malodor (foul odor)
Fever
Malaise
lymphadenopathy.

Necrotizing ulcerative
periodontitis in 45-year-old, HIVnegative, white male patient. A,
Buccal view of maxillary cuspid-

Necrotizing ulcerative
periodontitis in 45-year-old, HIVnegative, white male patient. B,
Palatal view of same area.

Necrotizing ulcerative periodontitis in

45-year-old, HIV-negative, white male
patient. C, Buccal view of mandibular
anteriors. Note the deep craters
associated with bone loss.

NUP

Clinical features of
NUP 4
Complications of NUP & severe
form of NUG:
=======================
====

Gangrenous (necrotic)
stomatitis: extensive necrotic
process to adjacent gingival
mucosa (check, palate, tongue,
floor of m., lips)

Necrotic
stomatitis

Necrotic
stomatitis

Noma (cancrum
oris)

Noma (cancrum
oris)

Microscopic
Finding

Microscopic
finding
Commonly similar to NUG
1- surface biofilm composed of a
mixed microbial flora with
different morphotypes and a
subsurface flora with dense
aggregations of spirochetes
(bacterial zone).
2- Dense aggregations of PMNs
(neutrophil-rich zone) .
3- Necrotic cells (necrotic zone).
4- Spirochetal infiltration zone.

HIV/AIDS
Patients

HIV/AIDS
Gingival and Patients
periodontal lesions
with distinctive features are
frequently found in patients with
HIV infection and AIDS.
- Linear gingival erythema (LGE),
and NUG, and NUP are the most
common HIV-associated
periodontal conditions reported in
the literature.
-NUP lesions found in HIV-

HIV/AIDS
Patients
- NUP lesions in HIV-positive/AIDS
patients can be much more
destructive and frequently result in
complications that are extremely rare
in non-HIV/AIDS patients.
- HIV-positive NUP may be extremely
rapid.
- Other complications:
- Large areas of soft tissue necrosis.
- Exposure of bone and sequestration of
bone fragments.

HIV/AIDS
Patients
Some researchers: reported that
the NUP to be a marker for
immune
deterioration
and
a
predictor for the diagnosis of
AIDS.
Other author: suggested that NUP
may be used as an indicator of
HIV infection in undiagnosed
patients.

HIV/AIDS
Patients

Shangase
etal
(2007)
reported that a diagnosis of
NUG or NUP in systemically
healthy, asymptomatic South
Africans
was
strongly
correlated with HIV infection.
Of patients presenting with
NUG or NUP, 39 of 56 (69.6%)
were subsequently found to

Etiology

Etiology of NUP
Generally as NUG:

1- Bacteria role:
NUP in HIV-positive patients
demonstrated significantly greater
numbers of the opportunistic fungus
Candida albicans and a higher
prevalence of A.
actinomycetemcomitans, P. intermedia,
P. gingivalis, Fusobacterium nucleatum,
and Campylobacter species compared
with HIV-negative controls.

Etiology of NUP

Immunocompromised Status :
Clearly, both NUG and NUP
lesions are more prevalent in
patients with compromised or
suppressed immune systems.
Commonly in HIV-positive and
AIDS patients.

Etiology of NUP
Psychologic Stress
Stress increases systemic

cortisol
levels, and sustained increases in
cortisone have a suppressive effect on
the immune response by
microcirculation in gingiva and altered
phagocytic functions.

Some researchers:
Found that urinary levels of 17hydroxycorticosteroid were higher in
subjects with NUG than in all other
subjects diagnosed with periodontal

Etiology of NUP
Malnutrition
Direct evidence of the relationship
between
malnutrition
and
necrotizing periodontal disease is
limited
to
descriptions
of
necrotizing infections in severely
malnourished children.
Many of
including
mediated

the host defenses,

phagocytosis;
cellimmunity;
and

Etiology of NUP

Reduction of nutrients to
cells and tissues results in
immunosuppression and
disease susceptibility.
Malnutrition can predispose
an
individual
to
opportunistic infections or
intensify the severity of

Etiology of NUP

Other factors
- Smoking
- Plaque and other local
factors e.g. calculus

Treatment

Treatment
The treatment is mostly similar
to NUG
1- Lavage of necrotic tissue and
pseudomembrane
under
local
anesthesia.
2- Correction of the systemic
condition
as
possible
and
consultation
with
patients
physician .

4- Local and systemic antibiotics

5- Antiseptic mouth wash
(chlorhexidine)
6- Antifungal and antiviral drugs
7- Good nutrition and
enhancement the psychic status.
8- Oral hygiene instruction and
patient motivation to control
dental plaque.
9- Maintenance recall visits to
evaluate periodontal health and
observe the recurrence of lesions.

Exercise
Comparison between NUG
and NUP